The modern paradigm of graduate medical education in pediatrics is described as competency-based, but in most circumstances, the full potential of a competency-based approach to education and assessment has not been realized. A competency-based medical education (CBME) system should focus on specific and pre-defined outcomes to determine a trainee’s progress and readiness for their next phase of practice rather than simply the passage of time through training. CBME represents a philosophical approach to education and assessment that “begins with the end in mind” and involves implementation of education and assessment that is patient-focused and learner-centered. When organizing a training program to embrace a CBME philosophy, there are five generally accepted core components, which include (1) an outcome competency framework, (2) sequenced progression of learning, (3) tailored learning experiences, (4) competency-focused instruction, and (5) programmatic assessment (Van Melle et al., Acad Med 94:1002–9, 2019). In this chapter we will emphasize that “assessment is an educational design problem that needs a programmatic approach,” meaning that assessment should be considered throughout the process of designing a curriculum and not be an afterthought or simply be based on regulatory requirements (van der vleuten, Med Educ 39:309–317, 2005).